Prep U TTE Communication

The nurse manager is aware that nurses in the operating room are concerned about a proposed change in their working hours. Which is the nurse manager's best approach to addressing this problem and the nurses?

Relate the proposed change to the group's existing beliefs and values.

The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan?

Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique.

A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.

Hoarseness of more than 2 week's duration

Which communication technique is helpful in health teaching about relevant aspects of a client's well-being and self-care?

Informing

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?

Notify the surgeon about the tube's removal.

Which statement about laws governing the distribution of controlled substances is true?

Nurses are responsible for adhering to specific documentation about controlled substances

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

Objective

Which situation would require the nurse to use critical thinking and decision-making skills in providing genetics-related nursing care?

Providing fertility counseling to a young family with a 2-year-old child with cystic fibrosis

A nurse is interviewing a client to obtain a health history. Which would be considered a "usual or expected" response during the first session?

Rambling due to nervousness

The nurse in the preoperative setting is preparing the client for surgery. During completion of the preoperative checklist the client states, "I have a question about my surgery." What is the next action by the nurse?

The nurse in the preoperative setting is preparing the client for surgery. During completion of the preoperative checklist the client states, "I have a question about my surgery." What is the next action by the nurse?

The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as

pleural friction rub.

The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response?

"When 15 minutes have passed, I will ask your mother to show me how to instill the drops."

A 77-year-old client presents to the local community center for a blood pressure (BP) screening; BP is recorded as 180/90 mm Hg. The client has a history of hypertension but currently is not taking the prescribed medications. Which question is most appropriate for the nurse to ask the client first?

"Why are you not taking your medications?"

A pregnant woman with type 2 diabetes is scheduled for a laboratory test of glycosylated hemoglobin (HbA1C). What does the nurse tell the client is a normal level for this test?

6%

A parent brings his child to the emergency department after the child sustains a fall from a tree. The child has severe right arm pain. A radiograph shows a complete break in the humerus with multiple pieces of bone at the fracture line and the skin is not broken. This type of fracture is classified as:

A closed, comminuted fracture

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse?

A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's.

The nurse is documenting in the client's health record. Which information is most appropriate for the nurse to record as objective data? Select all that apply.

Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. Client's dressing is intact with scant amount of serous drainage. Client ambulated to end of hallway.

The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation?

Encourage the family members to express their feelings and listen to them in their frank communication.

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

Develop an alternate method of communication.

When teaching a client with antisocial personality disorder (ASPD), which approach would be most appropriate for the nurse to use?

Direct

The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room?

During the postoperative phase

Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition?

Hepatitis

The student nurse is caring for a 2 1/2-week-old in the newborn intensive care unit. Which term is most accurate when discussing this client?

Newborn

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?

Show respect for the client, and engage in open communication in getting to know the client.

The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?

When the patient has less than 30 mL for 2 consecutive days

A client has left-sided paralysis. The nurse should document this condition as left-sided

hemiplegia.

A nurse is caring for a boy preparing to undergo a dressing change. Which statement by the father lets the nurse know that the child's pain experience is at risk of being intensified?

"I hope that you will be a brave boy and not cry."

The nurse is caring for a client with cellulitis. The client responds, "I feel kind of 'blah'," after the nurse asks, "How do you feel?" After the client's reply, the nurse states, "Can you tell me what 'blah' feels like?" The client responds, "I don't have any energy, and I don't feel like doing anything." Using therapeutic communication, how should the nurse respond?

"Let's talk about infections, and how they heal."

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine if the client is positive for the disorder. Which statement by the nurse is most accurate?

"The diagnosis won't be based on the findings of a single test but by combining all data

The nurse has been injured with a needlestick while caring for a newly admitted client, and she goes to tell the charge nurse. What is the next thing the injured nurse should do?

Document the injury in writing.

Parents and their nearly 3-year-old child have returned to the clinic for a follow-up appointment. Which of the findings may signal a speech delay?

Uses two-word sentences or phrases

When collecting a health history on a child, what is important for the nurse to assess regarding the child's allergies? Select all that apply

allergies to any medications allergies to items other than medications, such as foods and animals reaction to the allergen severity of the allergy

A nurse is preparing a health promotion program for teenagers focusing on lifestyle choices. Which of the following methods used by the nurse will best ensure the success of the program?

creating a safe environment for sharing information

A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

identifying risks and ensuring future safety for clients

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation?

"Can you tell me where you are right now?"

The nurse is caring for a client who was diagnosed with hypertension six months ago with little improvement in symptoms. The client does not speak English and does not appear to understand any teaching that has been given. The nurse is using clinical reasoning to attempt to determine what is preventing this client from understanding and complying with the teachings. Which statement by the nurse would be most helpful in determining the answer to this issue?

"I wonder if there are other issues that are affecting this client's compliance, such as his ability to hear?"

A client in a semiprivate room is diagnosed with pediculosis corporis. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. How should the nurse respond?

"I'm sorry, but I can't share confidential information."

A client has a 10-year history of rheumatoid arthritis and is concerned now that the client's child is experiencing some morning stiffness and pain. What would be the most appropriate response by the nurse?

"There is some evidence that a genetic basis for the disease may exist, so you might want to have your child evaluated."

A health care researcher has identified the gene of interest in a particular genetic disorder as well as the gene's location, Xq97. Where would one find a gene named Xq97?

Band 9, region 7 of the long arm of the X chromosome

An infant diagnosed with nonorganic failure to thrive (NFTT) is being treated in the hospital. Which intervention would the nurse implement for this child to provide increased nutritional intake?

Document all feedings and the infant's response to the feeding.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed.

The nurse needs to perform an admission assessment for a client who does not speak the same language as the nurse. The client's wife is fluent in both the nurse's and the client's languages. When completing the physical assessment is critical in planning patient care, how should the nurse proceed?

Obtain a translator to assist with interpretation during admission assessment.

A 55-year-old client was admitted to the psychiatric unit after an incident in a department store in which the client accused a sales clerk of following the client around the store and stealing the client's keys. The client was subdued by the police after destroying a window display because voices had told the client that it was evil. As the nurse approached the client, the client says, "You're all out to get me, and you're one of them. They're Rostoputians and grog babies here." This demonstrates what?

Suspiciousness and neologisms

A nurse is meeting a client for the first time. The nurse observes that the client smiles appropriately but is using rambling speech while answering the nurse's questions. Which would most likely be the reason for this behavior?

The client is nervous and insecure.

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.

The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete.

A pregnant woman comes to the clinic for a prenatal visit for her third pregnancy. She reveals she had a previous miscarriage at 12 weeks and her 3-year-old son was born at 32 weeks. How should the nurse document this woman's obstetric history?

G3, T0, P1, A1, L1

A nurse caring for a client being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation?

Information is documented in separate forms by each healthcare professional.

A nursing instructor is teaching about taking a health history and how to elicit a chief concern. The instructor realizes a need for further education when a student makes which statement?

"Intensity refers to how often the concern occurs during the day."

A client with post-polio syndrome displays fatigue and decreased muscle strength. How should the nurse best respond to the client?

"Intravenous immunoglobulin infusion may help you."

Nursing students are learning about the importance of therapeutic communication in their pediatric course. The nursing instructor identifies a need for further teaching when a student makes which statement?

"It is best to stand when listening to a child to demonstrate knowledge."

The nurse reviews insulin administration with a client. Which statement best indicates that the client will continue to perform the procedure correctly?

"I wrote down the steps in case I forget what to do."

The client tells the nurse, "My mom is coming in to see me today," while sighing and looking out the window. The nurse states, "You don't seem very excited about the visit, is everything OK?" The client affirms. Using therapeutic communication, how should the nurse respond?

"I'm concerned that you are not exicited about your mother's visit, We can talk if you want."

A 52-year-old male client is admitted to the medical-surgical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He tells the nurse that he hasn't seen any blood in his stool and that he usually drinks a six-pack of beer a day. In trying to pinpoint the cause of the client's pain, which action would the nurse take?

Ask the client to tell her more about the pain.

The nurse is preparing a nursing care plan for a 2-year-old child with hearing impairment. Which intervention will be part of the plan?

Assess the child's ability to convey information.

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?

Complete cervical dilation (dilatation) and time of fetal birth

One of the phases of drug development is the post-marketing surveillance phase. Which activity is carried out during this phase?

Health care providers report adverse effects to FDA

Which statement is not true regarding a medication administration record (MAR)?

If the client declines the dose, the nurse does not have to document this on the MAR.

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

Incident report

A nurse is completing an abdominal assessment on a client suspected to have appendicitis. When the nurse applies and then releases pressure in the client's right lower quadrant, the client experiences tenderness. The nurse is documenting the presence of:

Rebound tenderness

A nurse is assigned to care for a 6-month-old infant hospitalized with diarrhea and dehydration. Because the infant does not have developed speech, what can the nurse do to communicate with the infant?

Sing to the infant.